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NPI Code Detail

MEDICARE: MARTHA JEAN GRAY RD

MEDICARE: MARTHA JEAN GRAY RD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered DietitianR166117TN

General Provider Information

NPI Number : 1366544108
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARTHA JEAN GRAY RD
Provider Business Mailing Address
First Line : 2742 DOW AVE
Second Line :
City : TUSTIN
State : CA
Zip : 92780-7242
Country : US
Telephone Number : 714-665-1600
Fax Number :
Provider Business Practice Location Address
First Line : 26991 CROWN VALLEY PKWY
Second Line :
City : MISSION VIEJO
State : CA
Zip : 92691-6528
Country : US
Telephone Number : 949-582-2002
Fax Number : 949-367-5200
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/02/2006
Last Update Date : 03/31/2011

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